Dr. Candace McNaughton, MD, MPH, is a board certified emergency medicine physician and Assistant Professor in the Department of Emergency Medicine at Vanderbilt University. Her long-term goal is to reduce the burden of cardiovascular (CV) disease due to hypertension among patients who seek emergency care, through impactful scientific inquiry. Her short-term goals, with support from this K23, are to gain 1) advanced skills in development and implementation of behavioral health interventions tailored to the unique sociodemographics of patients who seek emergency department (ED) care for CV disease; and 2) practical experience in behavioral and clinical research, including responsible conduct of research. Nearly 37 million Americans have uncontrolled hypertension, the most important modifiable risk factor for CV and kidney failure, with associated annual costs of more than $93.5 billion. Only 50% of patients have controlled blood pressure, and nearly 5 million patients visit the ED annually for uncontrolled hypertension. Medication adherence, or taking medications as prescribed, plays an important role in blood pressure control, particularly among patients who seek care in the ED for hypertension-related complaints. This proposal addresses the critical need to improve blood pressure control by focusing on patients in the ED for hypertension-related complaints; these patients are likely to gain significant benefit and are at high risk for poor clinical outcomes. Dr. McNaughton's primary mentor, Dr. Russell Rothman MD MPP, is a federally funded expert in cross-cultural health behavior interventions and health services research; her co-mentor, Dr. Alan Storrow MD is an expert in emergency cardiovascular research. During an institutional K12, Dr. McNaughton gained expertise in determinants of adherence, validated a mass spectrometry assay to directly measure medication adherence, and over nine months enrolled 300 ED patients with hypertension in a cohort study, of whom 95% have completed one-year follow-up. Drawing on her prior and ongoing research, Dr. McNaughton will accomplish the following research aims among ED patients with hypertension-related complaints: 1) develop an ED-based antihypertensive adherence intervention from successful clinic-based interventions using patient and provider feedback, and 2) in a randomized trial of 350 patients, test this intervention's impact on 1- and 3-month systolic blood pressure and antihypertensive adherence, compared to usual ED care plus education. This proposal responds directly to NHLBI's goals of developing and evaluating culturally appropriate interventions to improve patient behavior in order to enhance quality of care. In summary, this proposal is a crucial first step to better understand and address antihypertensive adherence among patients who are likely to gain significant benefit from ED visits as teachable moments. Dr. McNaughton will also gain expert mentorship, study design and execution skills, and experience vital for a successful independent career in cardiovascular research.